Have you ever been interviewing a patient while there was family present and had the distinct feeling that the patient was the person least disturbed by his or her illness? Many times, it becomes evident in the first five minutes of an interview that a persons mental illness is wreaking havoc with not only his or her personal life, but also with the lives of those closest to the person. Based on a 1978 study of recently discharged patients with schizophrenia which found that a combination of medication therapy and crisis-oriented family therapy effectively diminished relapses, David Miklowitz and Michael Goldstein set out to create a similar intervention for patients with Bipolar Disorder. Family-Focused Therapy was the result. In their approach, there are four broad categories of basic skills: emphasizing positive feelings, active listening, making positive requests for change, and expressing negative feelings about specific behaviors. Bipolar Disorder: A Family-Focused Treatment Approach is a manual for their therapeutic approach and is organized so that it can be easily read cover to cover, or in chapters. Their principles make good clinical sense: include the support system in the treatment plan and compliance with treatment will increase and the relapse rate will decrease.

Bipolar Mood Disorder (also known as manic depression), with its extreme highs and extreme lows, extreme productivity and deep despair, can create intense pain, ruined family relationships, financial problems and lost hopes and dreams. It can also be a powerful motivating force. Just ask people like Tim Burton, Patricia Cornwell, or Kay Redfield Jamison(An Unquiet Mind, Touched With Fire: Manic Depressive Illness and Artistic Temperament, Night Falls Fast: Understanding Suicide). Thats why compliance with medication regimens is difficult. People like the highs and their increased productivity and creativity. This is where the family or support system comes into play. By having everyone on the same wavelength and with an understanding of each others needs, there is a greater chance that patients will have fewer, less severe relapses.

There are six objectives of FFT that are outlined in Miklowitzs and Goldsteins book: Assist the patient and relatives in

Integrating the Experiences Associated with Episodes of Bipolar Disorder,

Accepting the Notion of Vulnerability to Future Episodes,

Accepting a Dependency on Psychotropic Medication for Symptom Control,

Distinguishing between the Patients Personality and His or Her Bipolar Disorder,

Recognizing and Learning to Cope with Stressful Life Events that Trigger Recurrences of Bipolar Disorder, and

Reestablishing Functional Relationships after the Episode.

These six principles formalize the approach of including the family in patient treatment, giving structure to what is done intuitively. Having a roadmap to navigate a journey is key in getting to the intended distention

There is a brief, somewhat simplistic overview of bipolar mood disorder given early in the book, which serves those, not familiar with the illness. The book then lays out the steps of providing Family-Focused Treatment, from setting up the first encounter to termination of treatment. It is a stepwise approach to a three-phase model approach. There is the psychoeducational phase, communication enhancement phase (CET) and a problem-solving training phase. The phases are usually delivered in 12 weekly, six biweekly, and three monthly phases for a total of 21 treatments over nine months. The million-dollar question is whether or not this particular structure works and if so, is it better than any other approach? Although the data has not been published, the authors indicate that patients and families benefit from Family-Focused Therapy. If it does work, there is no reason not to have an extra tool in your therapeutic tool belt to approach the diverse presentations of patients with Bipolar Disorder.

Thomas Cobb, M.D. is currently a psychiatry resident at the University of Michigan. His interests include psychiatric resident education, neuropsychiatry, theology and religious history. He has reviewed psychiatric texts for other publishers and hopes to publish in the field soon. Future plans are in academic psychiatry with a focus on integrative approaches to the patient, from neurons to philosophy.

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